Childbearing women have a fundamental right to choose how, where and with whom they want to give birth, but in the United States women who choose to labor for a VBAC (known as TOLAC, trial of labor after cesarean) in a hospital are often being denied that right. Effectively giving thousands of women no choice but to concede to major abdominal surgery that put women and babies at risk for complications and mothers with multiple cesareans at risk for placental problems.

According to the National Institutes of Health (NIH), since 1996 about one third of hospitals and one-half of physicians have stopped providing care for VBAC. In 1996 the VBAC rate in the U.S. was 28%. Today it’s less than 10%. A report on the trends of home vaginal birth after a cesarean indicates that denial of access to care for VBAC has prompted an increasing number of women to labor for a VBAC at home.

Three out of four women who labor for a cesarean do give birth vaginally and the risks of major complications from laboring for a VBAC are less than 1%. The reason given by physicians and institutions to deny medical care for these expectant mothers have no foundation in science. Denying care for VBAC also presents a clear conflict of interest for providers and institutions who want to protect themselves from a potential medical malpractice suit, a frequent explanation given to deny care.

Physicians who do want to support these mothers are forced to pay additional malpractice insurance premiums and are often discouraged to support women who want to labor for a VBAC by their hospital’s administration.

Here is what the National Institutes of Health say about laboring for a VBAC:

Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.

Women who have a trial of labor, regardless of ultimate mode of delivery, are at decreased risk of maternal mortality compared to elective repeat cesarean delivery.

Comparing mothers (pregnancy with all gestational ages) with a uterine scar who labored for a VBAC with mothers who had a scheduled repeat cesarean the NIH found:

Maternal Mortality at Delivery

Per 100,000 live births

Women who labored for a VBAC

3.8

Women who had a planned repeat cesarean

13

For low-risk women, the risks of laboring for a VBAC are the same as for any other woman giving birth for the first time.

The risk of laboring for a VBAC is the possibility of a uterine rupture, the separation of the uterine scar from the previous cesarean. It is a serious medical emergency that occurs in less than 1% of VBAC labors and requires an immediate cesarean. Hospitals who deny women the option to labor after a cesarean say they cannot provide an “immediate” emergency cesarean as recommended in the American College of Obstetricians and Gynecologists (ACOG) guidelines for VBAC (Practice Bulletin #115) .

But, the National Institutes of Health concluded that there is no evidence to support ACOG’s selective safety recommendations for VBAC. The “immediately available” recommendation was based on consensus and expert opinion rather than strong support from high-quality evidence. Dozens of maternity care organizations and individuals also objected to the restrictive guidelines.

Women giving birth for the first time are also at risk for unpredictable complications that require an emergency cesarean. However, they are not denied medical care nor are they told that the hospital cannot provide an emergency cesarean, should they need one.

The NIH encouraged leaders in maternity care and insurance companies to work together to change the status quo and give more women access to medical care for those who want to labor for a VBAC.

ACOG and the Society of Maternal-Fetal Medicine recently admitted in their Safe Preventionof the Primary Cesarean guidelines that too many cesareans are being performed exposing mothers and babies to avoidable harms without improved outcomes. Providing low-risk women medical care to labor for a VBAC can reduce their exposure to the harms of a cesarean section.

Denial of Informed Consent and Informed Refusal

Physicians have an obligation to provide women with a prior cesarean with information about the benefits and risks for both repeat cesarean and for a VBAC. Women have the right to an informed consent or informed refusal of either options based on the accurate information provided.

Seeking informed consent expresses respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to support of the patient’s freedom to make decisions within caring relationships.

Refusing to provide medical care for women who want to labor for a VBAC and forcing them to “consent” to a repeat surgery denies their right to bodily integrity, self-determination and the freedom to make their own healthcare decisions. It also questions the integrity of that “caring relationship.”

Physicians have an ethical obligation to provide the best care possible for their patients including the primary ethical obligation, First Do No Harm.

Many hospitals and providers have found a way to safely support women who want to labor after a cesarean. All it takes is the will to make that happen.

Resources for Informed Decision Making and Childbearing Women’s Rights

Breech presentation occurs in 3-4% of all term pregnancies and is the third most common reason for performing a cesarean in the U.S. More than 90% of breech babies are delivered by planned cesarean section. External Cephalic Version (ECV), a procedure that helps to turn a fetus from a breech presentation to a cephalic presentation has been shown to decrease the incidence of breech presentation at term for women without a cesarean scar thereby reducing the need for a cesarean section. However, a study published in the January 2014 issue of the British Journal of Obstetrics and Gynaecology suggests it is safe for women with a prior cesarean to have an external cephalic version (ECV) in a medical center. This allows women to labor for a VBAC and reduce exposure to complications from a repeat cesarean.

The researchers in Spain compared a group of 70 low risk women with a prior cesarean with 387 low risk women with a prior vaginal birth who had an external version at or after 37 weeks of gestation. All women were expecting one baby. Physicians were successful in turning a breech in 67.1% of women with a cesarean scar and 66.1% of women with a prior vaginal birth. There were no complications in the group of women with a prior cesarean. Of the women with a prior cesarean 52.8% had a vaginal birth (VBAC). More than half of the women avoided a repeat cesarean section. Of the group of women without a prior cesarean 79.4% had a vaginal birth.

The authors of the study concluded that in addition to the 270 documented cases of uncomplicated ECVs for women with a prior cesarean, their data on 70 additional women that underwent the procedure without a uterine rupture or fetal mortality indicates that ECV is a safe option for women with a prior cesarean who want to labor for a VBAC.

Concern from the medical community for the complications of cesarean section and its impact on mothers and babies is mounting. Recently the American College of Obstetricians and Gynecologists and the Society For Maternal-Fetal Medicine issued Obstetric Care Consensus Statement: Safe Prevention of thePrimary Cesarean Delivery which called for physician restraint in performing cesarean sections. The guidelines offered safe directives for preventing the first cesarean including offering a breech version to women to reduce the odds for a cesarean section.

This study on the safety of external cephalic version for women with a prior cesarean adds to the existing evidence and may encourage clinicians to also offer the procedure to women with a prior cesarean who may want to labor for a VBAC.

New Jersey has one of the highest cesarean rates in the country. According to U.S. Preliminary data for 2012 New Jersey has the third highest cesarean rate in the nation, 38.7% preceded by Florida (38.1%) and Louisiana (40.2%). In the last two decades repeat cesarean births without labor more than doubled in New Jersey, from 40% to 85%. According to the New Jersey Department of Health currently one in four cesareans are routine repeat operations without serious risk indications. The New Jersey VBAC Task Force wants to change that.

Task Force members agree that VBAC should be available to all low-risk women who choose to labor after a prior cesarean and increasing access to VBAC would improve obstetric care. New Jersey hospital VBAC rates vary widely, from 31.0% at Monmouth Medical Center to 0% for Memorial Hospital and Southern Ocean Medical Center in 2011. The Task Force suggested establishing a network of regional VBAC referral centers who can meet safety requirements for VBAC. The Task Force is a multidisciplinary collaborative group which includes the New Jersey Hospital Association, health insurance payers and malpractice insurers.

Hospitals often deny VBAC care by referring to the costly and realistically unattainable ACOG guidelines which recommend a surgical team and anesthesia be “immediately available” when women labor for a VBAC. Having had a prior cesarean adds a level of risk to the subsequent laboring process, however, the risks of laboring for a VBAC are the same as for women giving birth for the first time, yet women giving birth for the first time are not denied medical care, nor are they told that they are at risk because the hospital cannot guarantee that a surgical team and anesthesia will be “immediately” available in case they would need a cesarean section.

The New Jersey VBAC Task Force concluded that ACOG’s definition of “immediate access” has never been defined by ACOG or any other authority and the legal liability of this ambiguous recommendation is “not conducive to frank discussion with patients, resulting in obscure and often misleading counseling.”

Providing safe medical care for women in New Jersey who want to plan a VBAC is not an impossible task. After more than one year of deliberations, the Task Force concluded that many of New Jersey’s hospitals already have the resources that can meet the safety standards recommended to support mothers who want to plan a VBAC. The Hospital Capacity and Regional Accessibility Subcommittee reasoned that being able to provide advanced neonatal care was just as critical for responding to complications that may develop during labor for a VBAC.

New Jersey licenses 20 hospitals as intensive perinatal centers or intermediate/regional perinatal centers. These hospitals are required to have full-time on-site coverage by neonatal and pediatric specialists and consulting arrangements with anesthesiology. Responding to a Task Force survey, 14 of 20 intensive care perinatal centers reported having 24-hour in-house obstetric coverage for cesarean, availability of anesthesia and operating room teams, and 60% of the intermediate and basic perinatal centers reported 24-hour on-site coverage and the rest the availability of an off-site obstetrician within 30 minutes once the need for a cesarean was established.

Also in response to the Task Force survey, 7 of the intensive perinatal care centers and 6 of the intermediate care centers were in favor of becoming a regional VBAC referral center.

To successfully increase access to VBAC the Task Force made several recommendations:

Re-evaluate the risks of laboring for a VBAC by comparing low-risk women with a prior cesarean with New Jersey’s benchmark population, low-risk multiparous women without a previous cesarean for a more realistic evaluation of potential maternal and neonatal complications.

Develop a VBAC education program to educate expectant parents about the benefits and risks of laboring after a prior cesarean.

Educate providers and hospitals about the benefits and risks of VBAC, adequate staffing and resources, labor progress patterns for VBAC , guidelines for augmentation of labor, signs and symptoms of uterine rupture or dehiscence and practice drills for appropriate response for a uterine rupture.

Educate in-hospital staff about VBAC including, risk management, nursing, anesthesiology, neonatology, lab and blood banks to have a more coordinated response in case of complications.

Providers should try to shift the focus of their conversation with their patients from “defensive communication and liability strategies toward true shared decision making.”

According to the CDC, although continued progress in initiating breastfeeding has been made over the last ten years in the U.S., infants are not breastfed for as long as recommended. More than 3 out of 4 mothers begin breastfeeding, but only 49% of babies are breastfeeding at 6 months and 27% at 12 months.

In an effort to educate maternity care professionals and childbearing families about the value of breastfeeding, the Coalition for Improving Maternity Services published a comprehensive fact sheet showing the evidence to support breastfeeding for mothers and all babies including premature and high-risk infants. The fact sheet shows that breast milk is the ultimate form of nutrition for babies and provides the best strategies for helping mothers initiate and maintain breastfeeding.

BREASTFEEDING IS PRICELESS

There Is No Substitute for Human Milk

A Coalition for Improving Maternity Services Fact Sheet

The World Health Organization (WHO), health care associations, and government health agencies affirm the scientific evidence of the clear superiority of human milk and of the hazards of artificial milk products. The WHO and the American Academy of Pediatrics recommend that mothers exclusively breastfeed their infants for the first six months, and continue for at least a year and as long thereafter as mother and baby wish.1

Human milk provides optimal benefits for infants, including premature and sick newborns. Human milk is unique. Superior nutrients and beneficial substances found in human milk cannot be duplicated. Breastfeeding provides optimum health, nutritional, immunologic and developmental benefits to newborns as well as protection from postpartum complications and future disease for mothers.

A U.S. Healthy People 2010 goal is to have three-quarters of mothers initiate breastfeeding at birth, with half of them breastfeeding until at least the 5th or 6th month, and one-fourth to breastfeed their babies through the end of the first year.2 In 2007 only four states met all five Healthy People 2010 targets for breastfeeding.3

Maternity Care Practices Greatly Affect Breastfeeding

Labor, birth, and postpartum practices can facilitate or discourage the initiation, establishment, and continuation of breastfeeding.4, 5, 6, 7 According to the U.S. Centers for Disease Control and Prevention (CDC), many birth facilities have policies and practices that are not evidence-based and are known to interfere with breastfeeding in the early postpartum period and after discharge.8 The World Health Organization,9 the American Association of Pediatrics,10 the American Academy of Family Physicians,11 and the Academy of Breastfeeding Medicine12 recommend that maternity health professionals provide birth and postpartum care that is supportive of breastfeeding.

The World Health Organization has identified the following intrapartum mother-friendly childbirth practices as supportive of breastfeeding:

minimizing routine procedures that are not supported by scientific evidence;

minimizing invasive procedures and medications; providing emotional and physical support in labor;

freedom of movement and choice of positions during labor and birth;

staff trained in non-drug methods of pain relief and who do not promote the use of analgesics or anesthetic drugs unless required by a medical condition;

no unnecessary induction or augmentation of labor, instrumental delivery, and cesarean section.13

The quality of care provided in the first 24 hours after birth is critical to the successful initiation and continuation of breastfeeding. Hospitals and birth centers which encourage and support breastfeeding are more likely to care for mothers and newborns in the following ways:

Provide mothers with breastfeeding support after hospital or birth center discharge. Support may include: a home visit or hospital postpartum visit, referral to local community resources, follow-up telephone contact, a breastfeeding support group, or an outpatient clinic.14

Benefits of Breastfeeding for Children

Enhanced Immune System and Resistance to Infections

The infant’s immune system is not fully mature until about 2 years of age. Human milk contains an abundance of white blood cells that are transferred to the child, acting to fight infections from viruses, bacteria, and intestinal parasites.

After the first month of life, rates of infant mortality in the U.S. are reduced by 21% in breastfed infants.

Breastfed infants are at lower risk for sudden infant death syndrome (SIDS).16

Protection Against Chronic Disease

Exclusive breastfeeding for a minimum of four months decreases the risk of Type I diabetes (insulin-dependent diabetes mellitus) for children with a family history of diabetes, and may reduce the incidence of Type 2 diabetes later in life.

Breastfed children are less likely to suffer from some forms of childhood cancer such as Hodgkin’s disease, and leukemia.

Breastfeeding reduces the risk for obesity, high blood pressure, and high cholesterol levels later in life.17

Human milk contains anti –inflammatory factors that lower the incidence of bowel diseases such as Crohn’s disease and ulcerative colitis.18

The incidence of asthma and eczema are lower for infants who are exclusively breastfed for at least 4 months, especially in families at high risk for allergies.19

Breastfeeding Premature and High-Risk Infants

Breastfeeding and banked human milk are protective and beneficial for preterm infants.

Hospitals and physicians should recommend human milk for premature and other high risk infants.20

Breast milk lowers the premature infant’s risk for gastrointestinal and infectious disease and reduces the incidence of necrotizing enterocolitis (inflammation with possible tissue death and perforation of the small intestines and colon).21

Women who breastfeed benefit from an increased level of oxytocin, a hormone that stimulates uterine contractions lowering the risk for postpartum bleeding. Women recover better with less blood loss at birth.

Exclusive breastfeeding frequently but not always delays the return of a woman’s ovulation and menstruation for a variable 20 to 30 weeks or more. This provides a natural means of child spacing for many.

Breastfeeding may enhance feelings of attachment between mother and baby.

Breastfeeding lowers a mother’s risk for developing ovarian and pre-menopausal breast cancer and heart disease, and may decrease the risk of osteoporosis later in life. The benefits increase the longer she breastfeeds.23

Breastfeeding women without a history of gestational diabetes are less likely to develop Type 2 diabetes later in life.24

The Cost of Not Breastfeeding

Private and government insurers spend a minimum of $3.6 billion dollars a year to treat medical conditions and diseases that are preventable by breastfeeding.25 Since children who are not breastfed have more illnesses, employers incur additional costs for increased health claims, and mothers lose more time from work to care for sick children.26

19. Greer FR, Sicherer SH, Burks AW, and the Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Pediatrics 2008;121:183-191.

20. American Academy of Pediatrics, 2005.

21. Agency for Healthcare Research and Quality, Evidence Reports and Summaries, 2007.

22. United States Breastfeeding Committee, 2002.

23. United States Breastfeeding Committee, 2002.

24. Agency for Healthcare Research and Quality, Evidence Reports and Summaries, 2007.

Maternity Care Professionals

Understanding the Dangers of Cesarean Birth: Making Informed Decisions

By: Nicette Jukelevics

Foreword by
Charles Mahan, M.D.

Critically examines the increasing use of cesarean deliveries for childbirth, the risks, outcomes, and other issues women need to consider to make an informed decision whether to have a natural birth or a cesarean.

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